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Younger people with rheumatoid arthritis are at increased risk of fracture even before age 50 years: a population-based cohort study

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Abstract

Summary

Less is known about the risk of fracture in people with rheumatoid arthritis aged under 50 than those in older age groups. The study shows that the risk of fracture before age 50 remains significantly higher in those with rheumatoid arthritis than matched controls. This has implications for fracture risk management.

Introduction

To determine the risk of first and subsequent fracture occurring before age 50 in people diagnosed with rheumatoid arthritis (RA) before age 50.

Methods

A retrospective observational cohort study of RA cases with matched controls using data from Clinical Practice Research Datalink (CPRD) of adults ≥ 18 years with diagnosis of RA recorded from 1992 to 2016 in the UK. Patients were followed from index date to the first fracture and subsequent fracture. A total of 36,858 cases were each matched to 3 controls. Incidence rates (IR) and incidence rate ratios (IRR) of first and subsequent fractures were calculated. A multivariate Cox’s proportional hazards model was used to calculate the risk of first fracture and of subsequent fracture in the presence of different risk factors.

Results

The IR of first and subsequent fractures at any age is significantly higher in cases than controls for patients with onset of RA at any age. This includes first fractures occurring before age 50 for those diagnosed with RA before this age. In women, the rate of first fracture before age 50 are significantly higher than matched controls (IRR 1.29 CI 1.12–1.49), the IRR for subsequent fracture is higher but not significantly so. For men, the IRRs of first and subsequent fractures below age 50 are also higher but not significantly so. Gender, previous fracture, glucocorticoid prescription, osteoporosis diagnosis, alcohol, smoking, and bisphosphonate prescription have a significant effect on the risk of first fracture at any age for RA patients; all these variables except osteoporosis diagnosis and alcohol have a significant effect on the risk of subsequent fracture and first fractures before age 50.

Conclusions

These results indicate an increased risk of first fracture before age 50 in people with RA diagnosed before this age. It is important that patients with RA of all ages are given timely support from the time of diagnosis to protect their bone health.

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Acknowledgements

The CPRD (ISAC) study approval number for this study is 15_190R. The work was previously presented at the EULAR Conference 2019 [31]. Thanks go to Professor Willie Hamilton and Dr Sarah Price for their invaluable support and advice.

Funding

This study was funded by a grant through the Pfizer competitive I-CRP funding programme (Pfizer Tracking Number WI202869).

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Authors and Affiliations

  1. Research Development & Innovations, Royal Cornwall Hospitals NHS Trust, Truro, UK

    J. Erwin & A. D. Woolf

  2. School of Medicine, University of Nottingham, Nottingham, UK

    D. G. Enki

Authors
  1. J. Erwin
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  2. D. G. Enki
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  3. A. D. Woolf
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Correspondence to J. Erwin.

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Key messages

What is already known about this subject?

People with rheumatoid arthritis have an increased risk of fracture due to a range of factors including osteoporosis, the use of glucocorticoids, chronic inflammation, and physical inactivity. This risk is recognized in older patients and fracture assessment is recommended for these patients. Less is known about the risk of fracture in people with rheumatoid arthritis aged under 50 and whether men and women in these younger age groups have similar risks.

What does this study add?

This study adds to the evidence that people with rheumatoid arthritis have an increased risk of having a fracture below age 50 compared to matched controls. In women, the incidence rate of first fracture before age 50 is significantly higher than in matched controls. This is not true of men. Taking into account age at diagnosis, gender, glucocorticoid steroid use, fracture previous to index date, osteoporosis diagnosis, smoking, alcohol and bisphosphonate diagnosis, the risk of first fracture before age 50 remains significantly higher in those with rheumatoid arthritis than matched controls.

How might this impact on clinical practice or future developments?

It is important that patients are given timely support to protect their bone health through diet, physical activity, and lifestyle changes and that their health providers are aware of the increased risk of fracture at all ages, not just in those aged over 50, so that such risks can be effectively managed. This needs to be reflected in policies and practice.

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Erwin, J., Enki, D.G. & Woolf, A.D. Younger people with rheumatoid arthritis are at increased risk of fracture even before age 50 years: a population-based cohort study. Osteoporos Int 32, 1651–1659 (2021). https://doi.org/10.1007/s00198-021-05862-1

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  • DOI: https://doi.org/10.1007/s00198-021-05862-1

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